(To be filled
up and submitted to the District Industries Centre after commencement
of production/activity[ The rows which have been repeated need to be filled only to the extent that actual details on commencement vary from those in Part I ])

ENTREPRENEURS MEMORANDUM NUMBER(Part I)

DATE OF ISSUE

MONTH OF COMMENCEMENT OF PRODUCTION/ ACTIVITY (MM/YYYY)

PERSONAL DETAILS

1.

Name Of Applicant

2.

Communication Address

Address

Website

Telephone Number

Fax Number

Cellphone Number

E-mail

Permanent Address

SAME AS THE ABOVE

Address

Website

Telephone Number

Fax Number

Cellphone Number

E-mail

NAME AND LOCATION OF ENTERPRISE

3.

Name Of Enterprise

Whether the Enterprise has been registered under PMT/ Filed EM PART II earlier

YES
NO

Address Of Enterprise

If Yes , Registration / EM No

4.

Location of Enterprise

State

Code

District

Code

Thehsil/Taluk/Mandal

Code

Panchayath/Municipality/Corperation

Code

Village/Town

Code

Pin Code

Ward & Buliding Number

Area(Rural-1,Urban-2)

Survey Number

CATEGORY AND ACTIVITY OF ENTERPRISE

5.

Category Of Enterprise(Micro-1,Small-2,Medium-3)

6.

Nature of Activity

Manufacture
Service

7.

Nature of Operation (Perennial-1,Seasonal-2,Casual-3)

8.

Whether the unit is an Anciliary(Yes-1,No-2)

9.

Month of Installation of Plant and Machinery (mm/yyyy)

10.

WHETHER THE UNIT IS REGISTERED UNDER FACTORY ACT

11.

Type Of Organization

PRODUCT DETAILS OF ENTERPRISE

12.a.

MAIN MANUFACTURING / SERVICE ACTIVITY

12.b.

PRODUCTS MANUFACTURED/SERVICE AND PROVIDED

13.

Investment in Fixed Assets(Rupees)

Land (Owned-01/Rented-02/Leased-03)

Approx. Value

Building (Owned-01/Rented-02/Leased-03)

Approx. Value

Plant and Machinery Value
(In case of manufacturing enterprise)

Equipment Value
(In case of service enterprise)

Foreign Equity , If any value)

14.

INSTALLED CAPACITY PER ANNUM

PRODUCT

QTY/Year

UNIT

1.

15.

POWERLOAD (ANTICIPATED) H.P /K.W.

H.P

K.W

16.

(a)

(i)

OTHER SOURCE OF ENERGY / POWER [IF REQUIRED]

(ii)

If no power required,specify reasons

(b) INDICATE ANNUAL REQUIREMENT SOURCE OF ENERGY

QTY

UNIT

EMPLOYMENT

17.

MALE(No.)

FEMALE(No.)

TOTAL(No.)

MANAGEMENT AND OFFICE STAFF

SUPERVISORY

WORKERS

18.

TOTAL ANNUAL TURNOVER(If less than one year of operation ,then expected turnover)

19.

EXPORT (if any) (in Rupees)

ENTREPRENEURS' PROFILE

20.

ENTREPRENEURS' PROFILE (OF ALL PARTNERS/DIRECTORS OF THE ORGANISATION )

NAME

GENDER

CATEGORY

KNOWLEDGE LEVEL

EQUITY PARTICIPATION (%)

STAKE IN OTHER ENTERPRISES

MF

21.

DATE OF COMMENCEMENT OF PRODUCTION / ACTIVITY(dd/mm/yyyy)

Date

Place

This is to certify that the information furnished in the memorandum is true and correct to the best of my knowledge and belief. I / We have obtained approval / consent / license / permit from the concerned Ministry / Department of Central Government / State Government / UT Administration as per statutory requirements.